A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E 000 Initial Comments E 000
From December 4 through 6, 2013, a renewal
survey was conducted at the above named facility
for the purpose of determining the facility's
compliance with COMAR 10.07.14, Assisted
Living Regulations. Survey activities included the
review of: policy and procedures, six (6) resident
records, seven (7) staff records, administrative
records, interviews with the Assisted Living
Manager (ALM), Delegating Nurse/Case Manager
#1 (DN/CM) and other staff and residents. A tour
of the facility was completed on December 4,
2013. At the start of the survey process on
December 4, 2013, the facility's census was
reportedly sixty four (64) residents'.
Based on the renewal survey findings, the
following deficiencies were identified;
E2550 .19 B2 .19 Other Staff--Qualifications
(2) As evidenced by a physician's statement be
free from:
(a) Tuberculosis, measles, mumps, rubella, and
varicella through appropriate screening
procedures such as tuberculosis skin tests,
positive disease histories, or antibody serologies;
and
(b) Any impairment which would hinder the
performance of assigned responsibilities;
This REQUIREMENT is not met as evidenced
by:
E2550
Based on staff record reviews on 12/04/13 the
facility failed to ensure that all staff records
contained; a physician statement and
documentation to support immunity to measles,
mumps, rubella, and varicella as evidenced by
history of disease or vaccination.
OHCQ
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
If continuation sheet 1 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E2550Continued From page 1 E2550
Findings included:
1. The AALM record failed to contain
documentation to support immunity to varicella.
2. The part time DN/CM's record failed to contain
a physician statement and documentation to
support immunity rubella.
3. Staff #1's Employee Health Survey
documented Staff #1 had not had mumps.
Review failed to reveal documentation of
immunization. Review revealed Staff #1 signed
an attestation he was "free of all communicable
disease" however further review failed to reveal
documentation of a positive disease history or
appropriate screening procedure for mumps.
4. Staff #2's Employee Health Survey was left
blank for measles, mumps, and rubella.
E2600 .19 B6,7 .19 Other Staff--Qualifications
(6) Receive initial and annual training in:
(a) Fire and life safety, including the use of fire
extinguishers;
(b) Infection control, including standard
precautions, contact precautions, and hand
hygiene;
(c) Basic food safety;
(d) Emergency disaster plans; and
(e) Basic first aid by a certified first aid instructor;
(7) Have training or experience in:
(a) The health and psychosocial needs of the
population being served as appropriate to their
job responsibilities;
(b) The resident assessment process;
(c) The use of service plans; and
E2600
OHCQ
If continuation sheet 2 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E2600Continued From page 2 E2600
(d) Resident's rights; and
This REQUIREMENT is not met as evidenced
by:
Based on staff record reviews and interview with
the ALM, the facility failed to ensure
documentation was available to support initial and
on-going/annual training's were completed.
Findings included:
1.) The part time DN/CM's training record failed to
contain documentation to support initial training in
basic first aid with certification of training.
2.) The AALM training record failed to contain
documentation to support initial training in health
and psychosocial process, resident assessment
and the use of service plans.
E2780 .20 C .20 Delegating Nurse
C. Duties. The delegating nurse shall:
(1) Be on-site to observe each resident at least
every 45 days;
(2) Be available on call as required under this
chapter or have a qualified alternate delegating
nurse available on call; and
(3) Have the overall responsibility for:
(a) Managing the clinical oversight of resident
care in the assisted living program;
(b) Issuing nursing or clinical orders, based upon
the needs of residents;
(c) Reviewing the assisted living manager's
assessment of residents;
(d) Appropriate delegation of nursing tasks; and
(e) Notifying the OHCQ:
(i) If the delegating nurse's contract or
E2780
OHCQ
If continuation sheet 3 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E2780Continued From page 3 E2780
employment with the assisted living program is
terminated; and
(ii) Of the reason why the contract or employment
was terminated.
This REQUIREMENT is not met as evidenced
by:
Based on resident record reviews and interview
with the ALM, the DN/CM #2 failed to assume
overall responsibility for: 1) Ensuring all
treatments/medications are administered
consistently with applicable requirements of
COMAR 10.27.11 (Nurse Practice Act)-and
Maryland Board of Nursing (MBON) Medication
Technicians' (MT) Course; 2.) Ensuring adequate
initial, 45-day reviews and 90 day reviews are
completed as required, 3.) Ensuring service plans
are completed and appropriate oversight of
medical services 4.) Reviewing the assisted living
manager's assessment of each resident.
Findings include:
Resident #5
1.) DN/CM #2 failed to ensure adequate
self-medicating reviews were completed for the
resident initially and every 90 days as required.
(Refer to tag 3560) The previous DN/CM failed to
ensure the resident's medication practice was
assessed every 90 days as required. Three (3)
assessments were found in the resident's record
and were dated as 3-2-13, 9-20-13 and 11-4-13.
More than 90 days had passed between 3-2-13
and 9-20-13 assessments.
2.) DN/CM #2 failed to ensure medical services
were documented on the resident's service plan
to ensure the facility's unlicensed MT received
proper directions for the completion of medical
services.
OHCQ
If continuation sheet 4 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E2780Continued From page 4 E2780
3.) The resident's full admission assessment was
completed on 2/21/13. The DN/CM #2
documented the full assessment was reviewed
on 9/2/12. However, DN/CM #2 failed to
acknowledge that the resident's communicable
disease portion of the assessment had not been
completed as required.
Resident #3
1.) Review of the resident's record revealed the
resident was transferred to the local hospital
twice in November 2013. The resident reportedly
was transferred out on 11/1/13 with complaints of
chest pain. The resident returned to the facility on
11/5/13 and DN/CM #2 completed the new
resident assessment tool on 11/6/13 but failed to
complete the new service plan as required when
utilizing the new assessment form.
2.) The resident was transferred back out to the
hospital on 11/12/13 for dehydration and returned
to the facility on 11/16/13. The DN/CM #2 failed to
complete a new resident assessment tool. The
resident's service plan was last dated as being
reviewed on 8/7/13; therefore the resident's
service plan was not up-dated upon return to the
facility on 11/16/13.
3.) Review of the resident's 45 day
reviews/comprehensive assessments revealed
the forms were completed by DN/CM #2 on
3/25/13 and 9/25/13. More than 45 days had
occurred between 3/25/13 and 9/25/13.
Resident #1
1.) The resident was admitted to the facility on
10/25/13 and review of the resident's record
revealed two resident assessment tools were
completed. The transferring facility completed a
resident assessment tool (utilizing old forms)
dated 10/17/13 by a Registered Nurse (RN).
DN/CM #2 completed a new resident assessment
OHCQ
If continuation sheet 5 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E2780Continued From page 5 E2780
tool (utilizing the Departments new assessment
tool) on admission. The resident's record failed to
contain a functional assessment and scoring tool
for the 10/17/13 assessment tool. In addition, the
resident's record failed to contain the new service
plan that is required when utilizing the new
resident assessment tool on admission.
2.) The resident was transferred to the local
emergency room (ER) on 12/2/13 after drinking
two and a half bottles of whiskey and falling on
the facility's front door steps and lacerating his
head and requiring six (6) staples for closure. The
resident's record failed to contain a resident
assessment tool (old or new) for the significant
change that occurred on 12/2/13. In addition, a
service plan had not been initiated as required on
admission and therefore was not up-dated with
services related to drinking and head trauma. The
facility's DN/CMs' are required to ensure all
medical services are documented onto the
resident's service plan.
3.) The resident's record failed to have a
comprehensive assessment to support the
DN/CM assessed the resident's medical condition
upon return from the ER on 12/2/13.
Resident #2
1.) Review of the resident's record on 12/05/13
failed to reveal a service plan. The surveyor
requested Service Plans on the dates of the
survey; none were provided. Resident #2 was
admitted to the facility on 10/31/13.
2.) Review of the resident's record revealed the
resident was on Coumadin, a high risk
medication which requires monitoring, was
assessed as at risk for falls, and had diagnoses
that included epilepsy, gait ataxia, and high blood
pressure.
OHCQ
If continuation sheet 6 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E2780Continued From page 6 E2780
Resident #6
Review of Resident #6's record revealed
numerous diagnoses including polysubstance
abuse, alcohol abuse, hepatic encephalopathy,
and cirrhosis. Further record review revealed the
resident continued to engage in behaviors that
are self-injurious. The 10/08/13 Resident
Assessment Tool by DN/CM #2 noted the
resident continues to consume alcohol and after
consuming alcohol has become agitated and
verbally aggressive with staff. The 11/18/13
Comprehensive Nursing Assessment by DN/CM
#1 documented the resident was diagnosed with
alcohol dementia with short term memory loss
and impaired decision making. DN/CM#1 did not
note any self injurious behaviors/aggressive
behaviors that were documented in the
progress/weekly care notes by staff. (Refer to
Tag E3960).
Nursing overview by the DN/CM includes the
development and evaluation of resident Service
Plans.
E3370 .26 C2 .26 Service Plan
(2) The service plan is developed within 30 days
of admission to the assisted living program; and
This REQUIREMENT is not met as evidenced
by:
E3370
Based on resident record reviews and interview
with the ALM the facility failed to ensure service
plans were completed within 30 days of the
resident's admission when utilizing the old
resident assessment tool and on admission when
utilizing the new resident assessment tool.
Findings include:
OHCQ
If continuation sheet 7 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E3370Continued From page 7 E3370
Resident #5
The resident was admitted to the facility on
3/2/13. Review of the resident's record on 12/5/13
revealed that the resident's service plan was not
completed or initially signed and dated by the
individual that initiated the start of the resident's
service plan. However, an attachment to the
service plan documented that the resident's
service plan was reviewed by four (4) staff on
9/26/13.
Resident #1
The resident was admitted to the facility on
10/25/13. Review of the resident's record on
12/5/13 revealed that the resident's service plan
had not been initiated as required on admission.
Resident #2
Review of the resident's record on 12/05/13
revealed the resident was admitted to the facility
on 10/31/13. Further review failed to reveal a
Service Plan.
E3420 .27 D .27 Resident Record or Log
D. Resident Care Notes.
(1) Appropriate staff shall write care notes for
each resident:
(a) On admission and at least weekly;
(b) With any significant changes in the resident's
condition, including when incidents occur and any
follow-up action is taken;
(c) When the resident is transferred from the
facility to another skilled facility;
(d) On return from medical appointments and
when seen in home by any health care provider;
(e) On return from nonroutine leaves of absence;
and
(f) When the resident is discharged permanently
E3420
OHCQ
If continuation sheet 8 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E3420Continued From page 8 E3420
from the facility, including the location and
manner of discharge.
(2) Staff shall write care notes that are
individualized, legible, chronological, and signed
by the writer.
This REQUIREMENT is not met as evidenced
by:
Based on resident record review the facility failed
to ensure resident care notes documented an
initial admission note and then weekly notes as
required.
Findings include:
1. Resident #5's record failed to contain an initial
admission note for 3/2/13.
2. Review Resident #1, #3 and #5's care notes
revealed weekly care notes were not being
completed as required. Weekly care notes
stopped the week of 11/18/13 for the three
residents'.
E3560 .29 E .29 Medication Management and
Administration
E. For a resident who is capable of
self-administration or, although capable, requires
a reminder or physical assistance, as stated in
§D(2) of this regulation, the assisted living
manager shall ensure that the resident is
reassessed by the delegating nurse quarterly for
the ability to safely self-administer medications
with or without assistance.
This REQUIREMENT is not met as evidenced
by:
E3560
Based on Resident #5's record review,
OHCQ
If continuation sheet 9 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E3560Continued From page 9 E3560
observation of the resident's self-medication
abilities, and resident interview on 12/6/13, the
DN/CM failed to complete an adequate
assessment of the resident's self-medication
administration skills and review of medications
being administered by the resident.
Findings include:
Interview with Resident #5 with review of
medications and administration practices
revealed the following deficient practices:
1.) Resident #5's bedroom was not locked upon
entering his bedroom. Medications were
observed unsecured on top of the small kitchen
counter. Two weekly pill containers were
observed with medications contained within and a
few bottles of medications were sitting out on the
counter. A bigger container of pill bottles was
removed from the kitchen cabinet. COMAR
10.07.14.L.(1) & (2)
2.) The medications were not maintained within
their original container as required and the
resident was not able to identify the pills within the
pill containers. COMAR 10.07.14.L.(1) & (2)
3.) Interview with the resident revealed the
resident did not know the names of the
medications or the reason for each medication
ordered. The resident said that he can read and
was able to put the pills into the containers.
4.) The facility's list of medications that the
resident reportedly was taking did not compare
with the medication found in the resident's room.
The resident stated that no one has come into his
room to review his medications with him. Eight (8)
medications found in the resident's room were not
on the facility' list of medications. The dose of
Synthroid (for hypothyroidism) had changed twice
from the dose that was originally written on the
facility medication list. The resident stated that he
OHCQ
If continuation sheet 10 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E3560Continued From page 10 E3560
stopped taking his Lasix (fluid pill). The resident's
Nitrostat (emergency heart medication) ordered
for chest pain had expired on 3/27/12. A clear
plastic bottle contained several pills and the bottle
was labeled "Ex-lax" with a permanent black pen.
No direction for use, strength of pills or expiration
date was documented.
5.) The resident's record revealed a
self-medication review was completed by the
DN/CM #2 on admission on 3/2/13; however the
resident's Nitrostat had expired prior to
admission. The next two (2) resident
assessments were dated 9-20-13 and 11-4-13,
however neither documented the above errors
observed on 12/6/13.
E3680 .29 M .29 Medication Management and
Administration
M. Medications and treatments shall be
administered consistent with current signed
medical orders and using professional standards
of practice.
This REQUIREMENT is not met as evidenced
by:
E3680
Based on resident record review, observation,
and interview of DN/CM#1 and staff, medications
transcribed onto Medication Administration
Records (MAR) were not consistent with current
signed orders and staff failed to follow standard
medication administration procedure.
Findings included:
RESIDENT #2
1.) Observation of a 12/04/13 medication pass by
Staff #3, a MT, revealed staff was preparing to
OHCQ
If continuation sheet 11 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E3680Continued From page 11 E3680
administer Coumadin 2mg. (milligrams) to the
resident. Review of the MAR revealed "HOLD"
was written in the 12/02/13-12/04/13 medication
boxes indicating the medication was not to be
administered. The surveyor asked the MT why
the dose was being administered and the MT
stated that LPN #1 told the MT not to hold the
medication. Review of the medication orders in
the MAR book failed to have any documentation
regarding holding/administering Coumadin on
those dates. Staff had initialed over the hold on
12/02/13 and 12/03/13 that doses were
administered. The surveyor contacted DN/CM#1
and the 12/04/13 dose was held until the DN/CM
could clarify. Interviews with DN/CM#1 and LPN
#2 revealed the LPN stated the resident was
scheduled for a dental procedure and she had
contacted the dentist who told her it was not
necessary to hold the Coumadin. The LPN had
not documented this information. The LPN was
not sure who wrote HOLD on the MAR but she
noted "error" above instead of re-writing the
medication on the MAR. The DN/CM followed up
with the healthcare provider on 12/04/13 and the
provider ordered the 12/04/13 Coumadin held.
2.) Review of the November and December, 2013
MAR's revealed Cyclobenzaprine 10 mg. at
bedtime as needed transcribed onto the MAR.
Review of the signed admission physician order
list revealed Cyclobenzaprine 5 mg at bedtime as
needed. The current pharmacy medication order
form noted Cyclobenzaprine 10 mg at bedtime as
needed. Further review failed to reveal a
physician order changing the dosage. Interview
with DN/CM#1 on 12/05/13 revealed the DN/CM
investigated the discrepancy during the survey
and stated the pharmacy had changed the
dosage in error.
OHCQ
If continuation sheet 12 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E3680Continued From page 12 E3680
RESIDENT #6
Review of the December, 2013 MAR revealed
staff was to apply Ketoconazole shampoo
topically three times weekly. Further review
revealed staff initialed the MAR 12/1/13- 12/04/13
indicating daily application.
E3790 .31 C .31 Incident Reports
C. All incident reports shall include:
(1) Time, date, place, and individuals present;
(2) Complete description of the incident;
(3) Response of the staff at the time; and
(4) Notification, including notification to the:
(a) Resident, or if appropriate the resident's
representative;
(b) Resident's physician, if appropriate;
(c) Program's delegating nurse;
(d) Licensing or law enforcement authorities,
when appropriate; and
(e) Follow-up activities, including investigation of
the occurrence and steps to prevent its
reoccurrence.
This REQUIREMENT is not met as evidenced
by:
E3790
Based on review of residents incident reports the
facility failed to ensure all required documentation
was recorded on each incident report as required.
Findings include:
1.) Review of Resident #1's record revealed the
resident had drank two and a half bottles of
whiskey on 12/2/13 and fell outside on the front
door steps of the assisted living facility at 1:30
am. The resident lacerated his head during the
fall that requires six (6) staples at the local
emergency room. The incident report
OHCQ
If continuation sheet 13 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E3790Continued From page 13 E3790
documented the resident was in and out of
consciousness. The incident report failed to
document preventative measure for the resident's
inappropriate and dangerous behavior. Review of
the resident's service plan revealed no
documentation or interventions to support
oversight of behavior by the assisted living facility.
2. ) Review of the facility's incident reports for the
last two weeks of October 2013 revealed several
incident reports failed to document; clear
description of events, preventative measure
taken by staff and notification of DN/CM:
a.) Incident report for bedroom 609 on 10/13/13
at 10:00 am documented a check mark to
indicate the resident fell. Staff documented that
the resident was found in a "Sitting position up
against door". Reportedly the resident's phone
rang and the resident lost their footing while trying
to get the phone. The DN/CM signed the incident
report on 10/17/13, four days after the incident
occurred and no documentation was found to
support the DN/CM was called at the time of
incident. The incident report failed to document
any preventive measures.
b.) Incident report for bedroom 420 on 10/13/13
at 7:15 am indicated the type of incident as
"other" and documented that the resident "Slide
off the couch while sleeping". Continued review of
the incident report revealed that staff documented
the resident was "Unable to tell me (staff
member) what happened". Staff failed to
document a clear description of events based on
conflicting documentation. The DN/CM signed the
incident report on 10/17/13, four days after the
incident occurred. The incident report failed to
document a preventive measure.
c.) Incident report for bedroom 510 on 10/27/13
at 8:30 am indicated the type of incident as
"other" and documented that the resident "Slide
OHCQ
If continuation sheet 14 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E3790Continued From page 14 E3790
from bed." No injuries were documented. Staff
documented that the resident's "bed is too high"
for the resident and the resident "has a hard time
getting in and out of bed". The DN/CM signed the
incident report the next day; however the area for
preventative measures was left blank.
d.) Incident report for bedroom 420 on 10/29/13
at 5:00 am indicated the type of incident as "fall"
and documented that the resident "Rolled off of
couch". The preventive measure was
documented as "What could be done is put bed
rails on bed and put resident to bed at night". The
DN/CM failed to sign this incident report as
reviewed. Bed rails are not appropriate as a
restrictive devise that may cause injury instead of
preventing it.
E3860 .33 D .33 Relocation and Discharge
D. In the event of a health emergency requiring
the transfer to an acute care facility, a copy of an
emergency data sheet shall accompany the
resident to an acute care facility. This data sheet
shall include at least:
(1) The resident's full name, date of birth, Social
Security number, if known, and insurance
information;
(2) The name, telephone number, and address of
the resident's representative;
(3) The resident's current documented
diagnoses;
(4) Current medications taken by the resident;
(5) The resident's known allergies, if any;
(6) The name and telephone number of the
resident's physician;
(7) Any relevant information concerning the event
that precipitated the emergency; and
(8) Appended copies of:
(a) Advanced directives;
E3860
OHCQ
If continuation sheet 15 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E3860Continued From page 15 E3860
(b) Emergency Medical Services (EMS/DNR)
Form; and
(c) Guardianship orders or powers of attorney, if
any.
This REQUIREMENT is not met as evidenced
by:
Based on resident record review and interview of
the ALM, the facility failed to ensure the
Emergency Data sheet contained all required
information.
Findings included:
Review of Resident #2's Emergency Data Sheet
on 12/05/13 failed to reveal documentation of all
diagnosis relevant to the resident. Additionally,
the sheet notes the resident is "CPR-Option A2"
but further record review failed to reveal a copy of
the MOLST (Medical orders for life sustaining
treatment). The ALM stated the MOLST form was
at the physician's office awaiting a signature.
E3960 .35 A1,2 .35 Resident's Rights
.35 Resident's Rights.
A. A resident of an assisted living program has
the right to:
(1) Be treated with consideration, respect, and full
recognition of the resident's human dignity and
individuality;
(2) Receive treatment, care, and services that are
adequate, appropriate, and in compliance with
relevant State, local, and federal laws and
regulations;
This REQUIREMENT is not met as evidenced
by:
E3960
Based on resident record reviews and interviews
OHCQ
If continuation sheet 16 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E3960Continued From page 16 E3960
of DN/CM#1 and ALM, the facility failed to have
documentation that the residents' service plan
were reviewed and revised when interventions for
behaviors with the potential to be harmful to self
and/or others were ineffective.
Findings included:
Resident #5
The resident was admitted to the facility on 3/2/13
and failed to have a service plan that was
completed and addressed his unsafe use of
alcohol consumption. The resident fell on 12/2/13
at 1:30 am in the morning on the facility's outside
front steps after consuming "two and one half
bottles of whiskey". The incident report failed to
document a preventive measure and the service
plan was not up-dated to address significant
change after the resident's ER visit, where six (6)
staples were required to close the laceration to
the resident's head. (Refer to Tag #3370 and
#3790 findings #1)
Resident #6
Review of Resident #6's record on 12/05/13
revealed the resident was admitted on 08/27/13
with extensive diagnoses including hepatic
encephalopathy, cirrhosis, bipolar disorder, mood
disorder, post traumatic stress disorder, alcohol
induced dementia, and had a history of homicidal
ideation, polysubstance abuse, and alcohol
dependence. Admission paperwork provided by
the Veteran's Administration (VA) revealed on
07/08/13 the VA plan included not using alcohol
for the next six (6) months and not exhibiting
behaviors that have the potential to be
self-injurious and/or to upset others.
Further review of the resident record revealed:
a.) Progress notes documented on 09/03/13 the
resident left the facility during the evening and
OHCQ
If continuation sheet 17 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E3960Continued From page 17 E3960
remained out of the facility until 12:00 AM and
returned smelling of alcohol. The resident also
refused to smoke "in appropriate areas." On
09/10/13 staff documented the resident was
observed utilizing stairs rather than the elevator
and safety issues were discussed however
resident continued to utilize stairs. On 09/23/13,
the AALM met with Resident #6 regarding use of
alcohol and continued use of stairs and safety
issues. On 10/02/13 staff documented resident
left facility on 10/01/13 and returned after
consuming alcohol. The resident became verbally
abusive toward staff and called then called 911.
Resident was admitted to the hospital and was
"physically and verbally violent" while in the
emergency room. On 10/14/13 the resident was
verbally abusive toward staff. On 12/04/13 staff
documented resident has medications in his room
that he stated were barbiturates. Notes
documented the resident's medical provider had
not prescribed any such medications. DN/CM#1
stated, during interview, the resident was not
allowing staff into his room to see the medication
and is threatening toward staff.
b.) Weekly care notes by staff documented on
10/28/13- "When drinking acts up and yells at
people". On 11/04/13 staff documented- "Goes
out in evening and misses meds." On 10/14/13-
"Resident leaves facility at times to consume
alcohol. Has been reported he is very
angry/verbally abusive toward staff."
c.) Caregiver documentation noted on 09/20/13
"very aggressive tonight. Cursing at staff and he
would be screaming & cursing at us in hallways of
all floors and slamming things." On 10/01/13 staff
documented "very loud & angry & rude."
d.) The 10/08/13 Resident Assessment Tool by
DN/CM#2 noted disruptive behavior "also has hx
(history) of alcoholism and continues to consume
alcohol on regular basis. After consuming alcohol,
OHCQ
If continuation sheet 18 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E3960Continued From page 18 E3960
resident has become agitated and verbally
aggressive with staff." Unsafe behaviors included
the continued use of alcohol.
e.) DN/CM#1's 11/18/13 Comprehensive Nursing
Assessment documented the resident was
diagnosed with alcohol dementia with short term
memory loss and impaired decision making.
DN/CM#1 did not note she was aware of the self
injurious behaviors/aggressive behaviors that
were documented in the progress/weekly care
notes by staff.
Review of Resident #6's record on 12/05/13
revealed a blank "Interim Service Plan". During
interviews with DN/CM#1 and ALM the surveyor
requested the Service Plan for the resident. None
was provided during the dates of the survey.
Review of Resident #6's record revealed the
resident was admitted to the facility on 08/27/13.
The ALM faxed a service plan to the surveyor on
12/09/13 with notes stating DN/CM#2 had
completed the plan. The typewritten plan was
dated 09/27/13; the signature areas and
corresponding date completed areas on page
eleven were blank. The plan stated the resident
"regularly consumes alcohol" (which is not
provided by the facility and is obtained when the
resident leaves the facility) and states "staff is to
encourage resident to refrain from alcohol
consumption" yet the plan further notes the
resident goes on walks and "usually walks to
town for the evening. Resident frequently returns
to facility after 10pm" and care notes prior to
09/27/13 document the resident leaves the facility
and consumes alcohol. The plan fails to develop
interventions to address this behavior.
Review of the resident record and interviews of
DN/CM#1 and the ALM failed to reveal the facility
had implemented effective interventions for
OHCQ
If continuation sheet 19 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E3960Continued From page 19 E3960
Resident #6, who exhibited behaviors that were
self injurious and behaviors that were aggressive
toward others. Interview with the ALM and
DN/CM#1 revealed the resident's whereabouts
are unknown during his absences' and staff does
not know when he will return. Staff
encouragement to refrain from alcohol
consumption is not effective and the resident is
consuming alcohol while away from the facility.
Record review revealed the behaviors continued
after 09/27/13. Review failed to reveal the facility
reviewed and revised the resident service plan
following continued self injurious
behaviors/aggressive behaviors documented in
the record that may place resident at risk of harm.
E4630 .41 A .41 General Physical Plant Requirements
.41 General Physical Plant Requirements.
A. The facility, which includes buildings, common
areas, and exterior grounds, shall be kept:
(1) In good repair;
(2) Clean;
(3) Free of any object, material, or condition that
may create a health hazard, accident, or fire;
(4) Free of any object, material, or condition that
may create a public nuisance; and
(5) Free of insects and rodents.
This REQUIREMENT is not met as evidenced
by:
E4630
Based on resident record review, interview of the
AALM, and observation, the facility failed to
ensure the environment was free from conditions
that may create a health hazard.
Findings included:
OHCQ
If continuation sheet 20 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E4630Continued From page 20 E4630
During a tour of the facility on 12/04/13 the
surveyor observed a can of beer in 5th floor
refrigerator and a bottle of beer in the 4th floor
refrigerator. The refrigerators are located in front
of the laundry rooms and accessible to all
residents and staff. Resident record reviews on
12/05/13 revealed two residents had a history of
alcohol dependence and documentation revealed
both residents continued to drink alcohol against
medical advice. The storage of alcoholic
beverages in community refrigerators accessible
to all residents creates a health risk.
E4910 .46 E3 .46 Emergency Preparedness
(3) Semiannual Disaster Drill.
(a) The assisted living program shall conduct a
semiannual emergency and disaster drill on all
shifts during which it practices evacuating
residents or sheltering in-place so that each is
practiced at least one time a year.
(b) The drills may be conducted via a table-top
exercise if the program can demonstrate that
moving residents will be harmful to the residents.
(c) Documentation. The assisted living program
shall:
(i) Document completion of each disaster drill or
training session;
(ii) Have all staff who participated in the drill or
training sign the document;
(iii) Document any opportunities for improvement
as identified as a result of the drill; and
(iv) Keep the documentation on file for a
minimum of 2 years.
This REQUIREMENT is not met as evidenced
by:
E4910
OHCQ
If continuation sheet 21 of 226899STATE FORM 88Z411
A. BUILDING: ______________________
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X3) DATE SURVEY
COMPLETED
PRINTED: 06/05/2014 FORM APPROVED
(X2) MULTIPLE CONSTRUCTION
B. WING _____________________________
Office of Health Care Quality
01AL044 12/06/2013
NAME OF PROVIDER OR SUPPLIER
KENSINGTON ALGONQUIN, LLC
STREET ADDRESS, CITY, STATE, ZIP CODE
ONE BALTIMORE STREET
CUMBERLAND, MD 21502
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
ID
PREFIX
TAG
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
E4910Continued From page 21 E4910
Based on review of the facility's disaster drills for
2012 and 2013, the facility failed to provide
evacuation drills for all three (3) shifts for the first
half of 2013.
Findings include:
The facility failed to have documentation to
support evacuation drill was completed on
evening shift for the first half of 2013.
OHCQ
If continuation sheet 22 of 226899STATE FORM 88Z411
Top Related